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Cardiovascular Associates of Northern Wisconsin, S.C. is an Equal Opportunity Employer and abides by local, State, and Federal law in regard to discrimination, because of age, race, sex, national origin, religion or physical handicap. Applications are kept on file for 30 days.

Fields marked with  * are required.

APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer
PERSONAL DATA
First Name:  * M.I.:  * Last Name:  * Social Security Number:  *
Home Address:  *
City/State/Zip City:  * State:  * Zip:  *
Telephone:  *
Email Address:
In case of emergency notify:  * Telephone:  *
Are you 18 years of age or older?
Verify Age
 *
Are you legally eligible for employment in the U.S.A?
Legally Eligible
 *
Can you perform all the tasks of the job for which you have applied
Perform All Tasks
 *
Position Applied For:  * When could you start?:
MILITARY
Were you in the U.S. Military Service:
Military Service
 If yes, what branch?
Date of Service: Rating or Rank Achieved
Did you receive an honorable discharge?
Honorable Discharge
EDUCATION
Institution Name & Location of School No. of Years Attended Course of Study Diploma or Degree(s) Acquired
 *
Characters remaining: 		 *
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Characters remaining: 		 *
Characters remaining:

Characters remaining:
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Computers, equipment or software you can operate that are related to the position for which you are being considered:

Characters remaining:
EMPLOYMENT HISTORY
(Start with the most recent)
Employer: Address
Telephone Number: Position Title
Primary Responsibilities:
From: To:
Starting Salary: Leaving Salary:
Supervisor's Name: Reason for Leaving:
Employer Information
Employer: Address
Telephone Number: Position Title
Primary Responsibilities:
From: To:
Starting Salary: Leaving Salary:
Supervisor's Name: Reason for Leaving:
Employer Information
Employer: Address
Telephone Number: Position Title
Primary Responsibilities:
From: To:
Starting Salary: Leaving Salary:
Supervisor's Name: Reason for Leaving:
READ CAREFULLY BEFORE SUBMITTING

I understand that in the event I am employed by the corporation, I am employed “at-will,” which means the term of employment is not definite and my employment may be terminated at any time, with or without cause, or notice, by either myself or my employer. The aforementioned constitutes the entire agreement between the Corporation and myself on the subject of termination, lay off and/or discharge and can only be changed by a written agreement signed and executed by the President of the Corporation.

I represent that the answers and information given by me in this application are true and complete to the best of my knowledge. Without limiting the at-will employment relationship, I understand that my employment may be terminated at any time if you discover that I have provided incomplete, untrue or misleading answers in this application, or on any other document or form executed by me at any time during my employment.

I hereby authorize you to verify the information given and to investigate my background as deemed necessary. I authorize former employers, personal references, or any other agencies, institutions or persons (collectively referred to as “person”), to provide to you any information they have regarding me without receiving written notice from me. I hereby release and agree to hold harmless from liability and covenant not to sue any person providing information pursuant to this authorization. I hereby waive my right to written notice by my present and/or former employers whenever a disciplinary report, letter of reprimand or other disciplinary action regarding me is divulged to you by present or former employers.

I understand that an investigative consumer report may be ordered by the Corporation on my character, general reputation, personal characteristics and mode of living and that the Corporation will, upon my written request provide me with additional information as to the nature and scope of any such report.

Submitting this form constitutes a signature on this application.

Signature:  * Date: December 3, 2008
 
500 Wind Ridge Drive, Wausau, WI 54401 715-847-2611 800-441-4013 HOURS: 7am - 5pm M-F